Diagnosis and Management of the Painful Shoulder. Part 2: Examination, Interpretation, and Management

Abstract

Diagnosis, interpretation and subsequent management of shoulder pathology can be challenging to clinicians. Because of its proximal location in the schlerotome and the extensive convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns can be broadly distributed to the deltoid, trapezius, and or the posterior scapular regions. This pain behavior can make diagnosis difficult in the shoulder region, as the location of symptoms may or may not correspond to the proximity of the pain generator. Therefore, a thorough history and reliable physical examination should rest at the center of the diagnostic process. Effective management of the painful shoulder is closely linked to a tissue-specific clinical examination. Painful shoulder conditions can present with or without limitations in passive and or active motion. Limits in passive motion can be classified as either capsular or noncapsular patterns. Conversely, patients can present with shoulder pain that demonstrates no limitation of motion. Bursitis, tendopathy and rotator cuff tears can produce shoulder pain that is challenging to diagnose, especially when they are the consequence of impingement and or instability. Numerous nonsurgical measures can be implemented in treating the painful shoulder, reserving surgical interventions for those patients who are resistant to conservative care.

Ergonomic Pain––Part 2: Differential Diagnosis and Management Considerations

“…For external impingement the subacromiodeltoid bursa and or external surface of one or more rotator cuff tendons are irritated by surrounding structures of the coracoacromial arch. On the other hand, internal impingement is the consequence of impact loading between the internal fibers of the rotator cuff and the labrum or glenoid limbus 3 …”

“…Clinically, the patient with external impingement presents with pain in the C5 distribution, especially during mid‐range elevation 22 . In addition, the individual may demonstrate an external impingement test, whereby the clinician stabilizes the shoulder girdle, then internally rotates the humerus, passively flexes the shoulder to 90°, horizontally adducts the arm, and finally stresses the shoulder into end‐range internal rotation 3 …”

“…Injections or iontophoresis can be used to reduce pain associated with bursal inflammation 29 . After 3 to 4 days rest, clinicians can follow injection or iontophoresis with “bursal massage,” 3 which can activate the subacromial gliding mechanism 19 . Conversely, transverse friction can be used to reduce pain associated with impingement tendopathies 29 .…”

“…Finally, any posterior capsular limitations should be addressed with glenohumeral mobilization to restore normal glenohumeral internal rotation 34 . Finally, the clinician should address any limits in the sternoclavicular and acromioclavicular joints through joint‐specific mobilization in a position of end‐range arm elevation 3 …”

Accuracy of Two Ultrasound‐Guided Coracohumeral Ligament Injection Approaches: A Cadaveric Study

“…Invasive and conservative treatments targeting the CHL have been described in the literature. Interventions include arthroscopic surgical release, microadhesiolysis, stretching, and manual therapy . The listed treatments yielded favorable outcomes: the surgical release of the CHL saw a decrease in pain, microadhesiolysis brought significant changes in pain and an increase in shoulder range of motion, and more conservative treatments yielded an overall increase in function with a decrease in reported pain .…”